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03-22-0000 10t22AN FROI1 TO 23405 8 P.03 <br />WELL PERMIT APPLICATION FORM <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br />304 E. Weber, Third Floor, Stockton, CA., 95202 <br />(209) 468-3449 <br />NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />UNIT IV <br />Application is hereby made to San Joaquin County for a permit to construct andlor install the work described This application is made in compliance w t-. <br />San Joaquin County Development Title, Chapter 9-1115 3 and the Standards of San Joaquin County Public Health Services, Env.ronmenta', Health Div-s.C^ <br />^�'d1 v-7 <br />Assessors <br />�j J; I n•j �£i f cam, 1i 'r C� / Cro s Street City 'J -for is I 1 � o Zip�i ,7 Parcel /y"7// "Cx / - �� / <br />BLL Location lI <br />PROPERTY OwnerC' . l y b �>�� k �"cfd�re„ss� City Zip CT h z3 r,oneM <br />C-57 Contractor V q (1V �l I nc\ Address ►ate', V4'� �/� city �leC•1 Zipq�),(,,1/L,cz1( hone (1- /L 777f/l?D <br />// l JJI /0iif!• ir;e iik:c'c--r <br />Consultant / Sub Contra ctotC..0ois �G'i ;Zli” / N Tt4Addres5c:.. It 5.4. fa City Sf"`< k '.t_i Phone- 7.01 .j 3vi- C-;718 <br />1W 7 <br />GIS Coordinates X Y Townsh o Range Sect,en <br />WORK TO BE PERFORMED <br />NEW WELL / BORING ( CPT GEOPROBE, HYOROPUNCH, HAND -AUGER. OTHER-) 0 DESTRUCTION (choose type oelov, <br />` <br />SOIL BORING+% h 5. r I �e % r , c� + ( : .a+4� tti: �� ✓ 0 OVER -BORE <br />f <br />' []WELL # F PRESSURE GROUT <br />'Other: y_ <br />h .�. f Z♦ t %mac : y In (,�C_'C��i,'Gbc pC� 1' rJn.�� , <Z �� L�< Ci .st �? t-G'Y -> 30 �C��C�p <br />v�.,..�c�.u1C? hci: �,�! �.. f'1. �'�rM'n✓L.rt <br />COMMENTS' �� ✓ SC r / `t ..✓ SC-.� .t.fo . hr- 1, it c� <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />'2 " <br />0 MONITORING 0 HOLLOW STEM DIA OF BOREHO'-E MULTIPLE CASINGS? 0 YES 0 NO WELL CASING DIA <br />0 EXTRACTION 0 AIR HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING U STEEL 0 PVC U OTHER <br />�) <br />0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED 0 AUGERS UH'OSG <br />I <br />0 AIR SPARGE PUSH POINT GROUT SEAL PUMPED yes p No (NOTE: MAXIMUM FREE -FALL DEPTH IS 30') <br />���((SOIL BORING 0 HAND AUGER APPROX BORING DEPTH C--) 0 BOLTED TRAFFIC BOX or U STOVE PIPE <br />a OTHER0 OTHER CONDUCTOR CASING PROPOSED> ( if YES. list spec ficahons neve) <br />COMMENTS: t�� ✓UC1C innr2r�./ �t` /w� iy } (.. C S t�'C. k <br />—✓r <br />NOT15: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules <br />Homeowner or licensed agent's signature certifies the following "I certify that in the performance of the work <br />and Regulations Of the San Joaquin County <br />Is issued, I shall not employ persons subject to WORKERS' COMPENSATION Laws of California." Contractor's hiring or sun - <br />for which this permit <br />contracting signature certifies the following "I Cerrdy that in the performance of the worK for which this permit is issued, I shall employ persons subject to <br />WORKERS' COMPENSATION Laws of Ca1ifOm.9 " <br />CA,6L THE UNIT 1/ -INSPECTOR 48 WORKING HRS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br />Title/Company / rCi.�C c ..1, C•c Ic, . ;S �[> rt��.' C.✓ t"%' <br />Si,c wi <br />Signedx� _J t J <br />Print Name DC; rG Date 3 "` � y <br />SEE ${TE MAP- IN ,UNIT 'lV WORK PLAN DATED::. aVeA1 V aC��� <br />DEPARTMENT USE ONLY G � <br />Application Accepted By ate Issued ?, I C. Area <br />Grout Inspection By Date-f)1,361h(5 nal Inspection By Date <br />Destruction InspeCtion By Date 3 31 �� <br />COMMENTS / CONDITIONS: <br />ACCOUNTING ONLY I AID# <br />PE CODES I FEE INFO I AMOUNT REMITTED I CHECK It I RECD BY I DATE <br />UF -ST C ( INVOICE <br />1/18 2000 <br />IL P. 03 <br />